For generations of military personnel, that phrase originating in World War II was the signal to take a break or at least to cool their heels while waiting. So ingrained was tobacco use in military culture, it was reasonable to assume that cigarettes would be an integral part of relaxing or, ironically, taking a breather.

A U.S. Army soldier from Charlie Company, 1st Battalion, 24th Infantry, took a smoke break while at a firing range in Qalat, Afghanistan this summer. DVIDS photo by Master Sgt. Jeffery Allen.

After all, cigarettes were included in C-rations until 1975 and still are sold without expensive taxes at military bases throughout the world.

So, persuading military personnel to give up smoking and creating a smoke-free military is, to say the least, a mammoth challenge.

“Tobacco products are culturally associated with the military, going back to companies providing cigarettes and rations in World War II. Pop culture, movies and television link cigarette use to machoism and military actions.”

Even as it has become increasingly stigmatized in civilian culture, “tobacco use remains socially acceptable in military culture. The military is a much different environment,” said Steven S. Fu, MD, MSCE, co-associate director of the VA HSR&D Center for Chronic Disease Outcomes Research (CCDOR) at the Minneapolis VAMC.

Fu told U.S. Medicine that returning troops sometimes face culture shock when they come home and find their workplaces and many public facilities are smoke-free.

Yet, the smoking cessation efforts are worth it, not only for the health of young veterans, who smoke at much higher rates than the civilian population, but also for healthcare budgets, which strain under the cost of caring for smokers with preventable long-term health problems.

More than 30% of military personnel smoke, a rate 50% more prevalent than in the civilian population, according to an Institute of Medicine (IoM) report in 2009. That hinders military readiness in the short term, by harming physical fitness, vision and hearing, according to that report.

The longer-term costs are nothing short of astronomical. IoM found that DoD’s cost of treating tobacco-related diseases is estimated to be more than $500 million per year for medical care and $346 million in lost productivity. The VA, meanwhile, spent more than $6 billion in 2008 treating diseases such as chronic obstructive pulmonary disease and arteriosclerosis, which are strongly associated with smoking. The smoking rate among veterans treated at the VA (22%) also is higher than the civilian population.

Educating active-duty personnel and veterans about the dangers of smoking and other tobacco use is not enough to get them to stop. Programs supported by DoD and VA must approach the issue on different levels that speak to the specific population.

Also, despite the efforts to get servicemembers to quit using tobacco, some military practices continue to not only look the other way when it comes to smoking but to actually promote it.

“I don’t think anyone in the United States today doesn’t know smoking is bad for them,” said Rachel Widome, PhD, MHS, core investigator at the Minneapolis CCDOR. Yet, she said, the active-duty servicemembers she has interviewed “talked a lot about the benefits of using tobacco in the military. It is a stress reliever, something to do when you are bored, a way to socialize with other people and a way to take breaks.”

In some military facilities, smokers are allowed breaks, while nonsmokers are not, she said, so many “smoke because they get a break.”

In addition, according to Fitzpatrick, “there is less of a financial prohibitive for using tobacco products because of lack of state and federal taxes when purchased in military exchange,” so smoking-cessation programs find it more difficult to use cost as leverage to get military personnel to give up tobacco.